Cardiac Contusion
myocardial contusion
A bruise of the myocardium caused by blunt chest trauma, due to an RTA/MVA or fall from a height.Diagnosis
EKG/ECG, echocardiography, cardiac enzymes, coronary angiography or 201Tl myocardial perfusion single-photon emission tomography (SPECT) have been used to localise the injured myocardial walls; more recently, 18F-fluorodeoxyglucose positron emission tomography (FDG PET).
Cardiac Contusion (Myocardial Contusion)
| DRG Category: | 315 |
| Mean LOS: | 4 days |
| Description: | MEDICAL: Other Circulatory System Diagnoses With CC |
Cardiac (myocardial) contusion is a bruise or damage to the heart muscle. Damage to the heart ranges from limited areas of subepicardial petechiae or ecchymoses to full-thickness contusions with fragmentations and necrosis of cardiac muscle fibers. Cellular damage consists of extravasation of red blood cells into and between the myocardial muscle fibers and the selective necrosis of myocardial muscle fibers. Creatine phosphokinase leaks out of the cells into the circulation. Complete healing occurs with little or no scar formation. When myocardial injury is extensive, the pathological changes may resemble those seen in acute myocardial infarction, and the patient may experience some of the same complications associated with it, such as cardiac failure, cardiac dysrhythmias, aneurysm formation, or cardiac rupture. Severe trauma may cause valvular rupture, damage to the coronary arteries, or a fractured sternum.
Causes
Cardiac contusion can be caused by any direct traumatic injury to the chest. Most commonly, it is the result of a direct blow to the chest from a steering wheel injury in a motor vehicle crash, a sports accident, a fall from a high elevation, an assault, or an animal kick. Injury to the myocardium typically occurs as a result of acute compression of the heart between the sternum and the spine. The anterior wall of the right ventricle is most commonly involved because of its location directly behind the sternum.
Genetic considerations
Not applicable.
Gender, ethnic/racial, and life span considerations
Cardiac contusion can occur at any age and in both sexes, although more males than females are involved in traumatic events. Trauma is the leading cause of death between ages 1 and 45 in the United States. Anyone at high risk for traumatic injuries, such as children and young adults in the first four decades of life, is at high risk for myocardial contusion. Because their bones may be more brittle, elderly patients also have an increased risk; traumatic injury to the sternum is less tolerated by the elderly than by younger patients. Ethnicity and race have no known effect on the risk of cardiac contusion.
Global health considerations
No data are available.
Assessment
History
Elicit a thorough history of the injury event, including the time, place, and description. Determine the point of impact and any weapons (baseball bat, brick, fist) used in an assault. Patients usually describe the most common symptom of cardiac contusion—that is, precordial pain resembling that of myocardial infarction. However, coronary vasodilators have little effect in relieving the pain. It is important to note that many patients may be asymptomatic for the first 24 to 48 hours after the chest trauma. In patients with multiple trauma, physical signs may be masked by associated injuries. Note the presence of blunt chest injuries, such as sternal, clavicular, or upper rib fractures; pulmonary contusion; hemothorax; or pneumothorax—all of which raise suspicion for the possibility of a myocardial injury.
Physical examination
Generally, the physical signs of a cardiac contusion are few and nonspecific. Observe the chest wall for the presence of bruising, hematoma, swelling, or the imprint of a steering wheel if the patient has been driving a motor vehicle. Note the presence of pain (chest wall or musculoskeletal), dyspnea, tachycapnea, tachycardia, and diaphoresis. Be alert for the possibility of cardiac tamponade, active bleeding into the pericardial space that leads to myocardial compression, and cardiogenic shock. Note the presence of hypotension, muffled heart sounds, a paradoxic pulse, and shock from potential complications (Table 1).
| COMPLICATION | SYMPTOMS |
|---|---|
| Atrial dysrhythmias: Sinus tachycardia, atrial fibrillation, premature atrial contractions | Palpitations, precordial pain, dizziness, faintness, confusion, loss of consciousness |
| Cardiac tamponade | Hypotension, pulsus paradoxus, muffled heart sounds, pericardial friction rub, anxiety, restlessness, tachypnea, weak to absent pulses, pallor, cyanosis |
| Congestive heart failure | Orthopnea, tachypnea, crackles, frothy cough, distended neck veins, anxiety, confusion |
| Pulmonary edema | Pallor, cyanosis, dyspnea |
| Ventricular aneurysm | Chest pain, dyspnea, orthopnea |
| Ventricular dysrhythmias: Premature ventricular contractions, ventricular fibrillation | Palpitations, precordial pain, dizziness, faintness, confusion, loss of consciousness |
Psychosocial
The patient with a cardiac contusion usually has suffered an unexpected traumatic injury. She or he may have numerous other traumatic injuries that accompany the contused heart. Assess the patient’s ability to cope with the unexpectedness of the traumatic event. Assess the patient’s degree of anxiety regarding the traumatic event, injuries sustained, and the potential implications of the injuries. Note that trauma patients are often teenagers and young adults. During crises, the presence of their parents and peers is essential in their recovery but may challenge the nurse to provide a quiet and stress-free environment for patient recovery.
Diagnostic highlights
| Test | Normal Result | Abnormality With Condition | Explanation |
|---|---|---|---|
| Echocardiogram | Normal size, shape, position, thickness, and movement of structures | May identify injury to heart structures, such as echo-free zone anterior to right ventricular wall and posterior wall (cardiac tamponade), wall motion irregularities, aneurysm, or valvular rupture | Records echoes created by deflection of short pulses of ultrasonic beam off structures; may be done as transesophageal to left ventricular procedure with transmitter inserted into esophagus (transesophageal echocardiogram) |
| Electrocardiogram (ECG) | Normal PQRST pattern | ST segment depression, T-wave inversion; may have transient ST elevation (less frequent); ECG may be normal | Electrical conduction system adversely affected by myocardiac ischemia due to injury; 65% of people with myocardial contusion have ECG changes |
| Creatine kinase isoenzyme (MB-CK) | <5% of total CK | Elevated in some patients | Some patients with a cardiac contusion have actual tissue damage and therefore would have enzyme elevation |
| Serum cardiac troponin I | <0.6 μg/L | >1.5 μg/L | Suggests myocardial damage and necrosis |
Other Tests: Supporting tests include aspartate aminotransferase (also known as serum glutamic-oxaloacetic transaminase), lactic dehydrogenase, chest x-ray, computed tomography scans; ultrasonography to evaluate sternal fracture and valvular damage
Primary nursing diagnosis
Diagnosis
Chest pain (acute) related to injury, swelling, bruisingOutcomes
Comfort level; Pain control behavior; Pain level; Well-being; Symptom severityInterventions
Analgesia administration; Pain management; Medication management; Distraction; Vital signs monitoringPlanning and implementation
Collaborative
Management of patients with suspected or known cardiac contusion is similar to that of any myocardial ischemic problem. Strategies include oxygen therapy; cardiac and hemodynamic monitoring; analgesics; and, if necessary, antidysrhythmics and inotropic agents. Even in patients without obvious dysrhythmias, maintain intravenous access for treatment of complications that may be associated with myocardial contusion. Place the patient on continuous cardiac monitoring to assess for dysrhythmias. Perform serial monitoring of vital signs to determine if the patient’s heart function is changing. If signs of falling cardiac output occur (confusion or decreased mental status, delayed capillary blanching, cool extremities, weak pulses, pulmonary congestion, increased heart rate, decreased urine output), the physician may insert a pulmonary artery catheter.
One of the more severe complications of myocardial contusion is pericardial tamponade, which can develop more than 1 week after the injury. Elective surgery for associated injuries (open reduction of fractures, repair of minor facial fractures) involving general anesthesia may be delayed, if possible, until cardiac function is stable. Delay allows for stabilization and healing of the contusion, which lowers intraoperative and postoperative risk for cardiac complications.
Pharmacologic highlights
| Medication or Drug Class | Dosage | Description | Rationale |
|---|---|---|---|
| Antidysrhythmics | Varies with drug | Lidocaine is the treatment of choice for ventricular tachycardia or fibrillation that persists after defibrillation; others are bretylium, magnesium sulfate, procainamide, atropine, adenosine, esmolol, propagator, acebutolol | Control dysrhythmias; drug depends on type of injury |
| Inotropic drugs | Varies with drug | Dopamine, dobutamine, amrinone, milrinone | Increase contractility if failure occurs |
Other Drugs: Intravenous opiates such as morphine sulfate may be required in the acute phase for comfort and rest.
Independent
During recovery, nursing interventions focus on conserving the patient’s energy. Activity restrictions, including bedrest, may be necessary for a short period of time (usually 48 to 72 hours) to decrease myocardial oxygen demands and to facilitate healing. Discuss the need for activity restriction with the patient and family.
The young adult trauma patient presents a challenge to the nursing staff. Provide age-appropriate diversionary activities to reduce anxiety. If the patient is a high school student, note that the hospital may be overwhelmed with peers from the local high school who are interested in visiting the patient, particularly if the injury was associated with a school event (prom, football game, party) and if the injury is life-threatening. Work with the parents and principal to arrange for a visitation schedule so that both the patient’s and the hospital’s needs are met.
Evidence-Based Practice and Health Policy
Mascaro, M., & Trojian, T.H. (2013). Blunt cardiac contusions. Clinics in Sports Medicine, 32(2), 267–271.
- Children and adolescents who participate in contact sports are at increased risk for sustaining cardiac contusions and may be more susceptible to injury because of the elasticity and compressibility of their chest walls.
- There is currently no gold standard measure for determining the presence of cardiac contusion, nor are there guidelines for returning to play after a potential injury.
- Recommendations for reducing cardiac contusions and subsequent complications among adolescents in sports include prevention with the use of softer balls and chest wall protectors, identification of potential injuries through focused viewing from the sidelines, comprehensive assessment if an injury is suspected (even in the absence of fractures, ecchymosis, or chest pain), and immediate defibrillation and CPR if a blunt chest injury followed by a sudden collapse and loss of consciousness is witnessed.
Documentation guidelines
- Detailed observations and assessments of physical findings related to traumatic injury: Skin integrity, swelling, fractures, alignment, mental status
- Detailed assessment findings of respiratory and cardiac systems: Heart and lung sounds, vital signs, signs of complications, cardiac rhythm
Discharge and home healthcare guidelines
The patient may be sent home on oral analgesics and other medications to manage complications. Be sure the patient understands all medications, including the dosage, route, action, and adverse effects. Educate the patient about the symptoms of potential complications associated with cardiac contusions and instruct him or her to call the physician or go to the emergency department immediately if any of the associated symptoms occur.